Episode 10 - General Surgery: Part 3 - Appendicitis

Theme:
General Surgery

Participants:

Dr Michael Haddock (ED consultant), Dr Sergei Tsakanov (general surgical Fellow), Sunny Rajput (ED trainee), Edgardo Solis (general surgical registrar), Shreyas Iyer, Samoda Wilegoda Mudalige, Kit Rowe, Caroline Tyers, Harry Hong and Yelise Foon.

Discussion:
A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. The CODA Collaborative. (2020), 383(20), 1907-1919. https://doi.org/10.1056/nejmoa2014320.

Summary:

• This study was undertaken in the United States towards the end of their initial COVID-19 wave.
• The results were reported at 90-days, however, they still have analysis intended for the first 2 years (so it is an ongoing study).
• It looked at patients 18 years or older, with image-confirmed acute appendicitis in emergency departments across 25 centers in the United States.
• Septic, diffusely peritonitic, complicated, or recurrent appendicitis patients were excluded.
• The study compared antibiotics (with IV antibiotics for at least the first 24 hours, followed by oral antibiotics to complete a total 10-day course) with appendectomy.
• The primary outcome was a ‘general health survey’ which was conducted at the 24 hours, 1-, 2-, and 4-weeks, and 3-, 6- and 12 months following discharge.
• The secondary outcomes included resolution of symptoms, adverse events, complications (including abscess formation, C.diff infection, the requirement of a more extensive operation, perforation, and neoplasm rates), ED presentations related to appendicitis, length of stay in hospital, and days of missed work (for patients and caregivers).
• The results of this study found that antibiotics were non-inferior to appendectomy at 30-days according to the ‘general health survey’.
• However, representation to the emergency department was significantly higher for those treated with antibiotics (9% compared with 4% for appendectomy patients), as were adverse events.
• It is important to note that the presence of an appendicolith is an indicator for complicated appendicitis (carrying the risk of ischemia and subsequent appendiceal perforation) and an increased likelihood of failed management with IV antibiotics alone- however, such patients were included in this study.

Take-Home Points:

• Acute uncomplicated appendicitis may be considered for treatment with IV antibiotics alone, although an appendicolith would still exclude a patient from this at this stage in most cases.
• 10% of patients treated with IV antibiotics alone will fail in the initial treatment phase and may represent to the emergency department during their antibiotic course.
• Thus, the emergency department may start to see a new cohort of patients; rather than ‘post-operative complications’, we may start to see ‘post-non-operative complications’ (such as recurrence, intra-abdominal abscess, or those from antibiotics themselves).
• 7/10 of patients will be able to avoid an operation with antibiotics in acute uncomplicated appendicitis.
• However, long-term data (over the course of more than 5 years) is still required to characterize this issue further.

Credits:
This episode was produced by the ­­­­Emergency Medicine Training Network 5 with the assistance of Dr Kavita Varshney and, Deepa Dasgupta.

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See you next time,
Caroline, Kit, Pramod, Samoda, and Shreyas.

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